Every finding on record at Sierra Home Healthcare Services, Inc

The following reflects the findings of the Department of Public Health during a Recertification Survey.Representing the Department of Public HealthSurveyor ID #- RN-HFEN Surveyor ID #- 22303 RN-HFEN Unduplicated Admissions -454Active Patients -92Sample Size -10 PatientsHome Visit - 4

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the emergency preparedness plan that included training for all staffs was evaluated and updated at least annually. This failure had the potential for the staffs to lack the knowledge to respond effectively during an emergency situation. During a review of the emergency preparedness plan and disaster training of the HHA on 5/8/22, at 11:30 a.m., the HHA did not have evidence of Emergency Preparedness training/Disaster drill for all staffs and did not have documented evidence of an emergency plan annual review. During an interview with the Administrator (ADM) on 5/8/22, at 11:51 p.m., the ADM stated that the Emergency preparedness/Disaster drill training for the staff was not done annually. There was no documented evidence the governing body reviewed and evaluated the policy annually on Emergency Preparedness/Disaster. The HHA's undated policy and procedure titled, "Emergency Preparedness Plan," indicated “this emergency preparedness plan was designed to provide continuing care/service in the event of an emergency that would result in interruption of patient care services.”

The following reflects the findings of the Department of Public Health during a Recertification Survey.Representing the Department of Public HealthSurveyor ID #- RN-HFEN Surveyor ID #- 22303 RN-HFEN Unduplicated Admissions -454Active Patients -92Sample Size -10 PatientsHome Visit - 4

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on observation and interview, the HHA failed to ensure one of 10 sample patients (Patient 6) was aware of the HHA Complaint Hot line number and its purpose. The deficient practice has the potential for the complaints not being addressed, investigated, and not resolved by the agency staff that could lead to affect the quality of care and quality of life of the patients. A review of Patient 6’s clinical record on 5/6/22, at 5 p.m., indicated a start of care (SOC) 3/13/2022, with diagnoses of Krabbe Disease (an inherited disorder that destroys the protective coating (myelin) of nerve cells in the brain and throughout the nervous system with symptoms of unable to hold head, muscle weakness, and hearing/vision lost. There is no cure), and muscle weakness. During a review of the plan of care (POC- CMS 485), for the certification period of 3/18/2022 to 5/16/2022, included Physical Therapy (PT) to visit one time a week for one week and two times a week for four weeks to include mobility training, transfer training, therapeutic exercise program, safety training, fall prevention, and caregiver training to improve independence with functional mobility to decrease fall risk. Occupational therapy to evaluate and treat. During a joint home visit with LVN 1, Patient 6 and patient caregiver (PCG) on 5/7/2022, at 11: 00 a.m., were asked regarding the Complaint Hotline number and its purpose. Both Patient 6 and PCG stated they did not know about the Complaint Hotline number and its use. During an interview with the Administrator and DON on 5/8/2022, at 12:36 p.m.., they both stated all patients should know the use of the Complaint Hotline.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the skilled nurse (SN) failed assess the patient's pain in accordance to the plan of care (POC) for one of 10 sampled patients (Patient 2). This deficient practice placed the patient at risk for ineffective pain management and discomfort. A review for Patient 2's clinical record indicated a start of care date of 3/28/22, with diagnosis of diabetes mellitus ( a disease that result in too much sugar in the blood sugar). A review of Patient 2's plan of care from 3/28/22 through 5/26/22, included an order for the skilled nurse (SN) to visit daily for 60 days, to assess vital signs, endocrine (pancreas) status and sign and symptoms of significant changes reportable to the physician. The skilled nurse was to evaluate the patient's pain level every visit and the effectiveness of the pain medications. SN to report to the physician if pain levels above 8/10 (severe) and or greater not relieved by the prescribed medication/rest. A review of the skilled visit notes dated 3/29/22 through 5/1/22, indicated Patient 2 was assessed to have an intermittent pain level of 2-4/10 (mild to moderate pain - 0 as no pain and 10 as the worst pain) on the right hand and left lower leg. The intervention was rest and medication with Tylenol extra strength 500 mg every 6 hours to relieve pain. There was no documented evidence whether the intervention provided for pain was mitigated or not. During an interview with the director of patient care services (DPCS) on 5/8/22, at 10:30 a.m., she stated, "The pain management is incomplete." The agency's policy and procedure titled "Pain Assessment/Management dated 1/9/02" indicated the nurse/therapist includes all to assess the patient's pain, location, duration, severity (rating scale), alleviating factors, current treatment and response to treatment. The follow-up assessment will address effectiveness of the pain management program and identify if there is a need for referral for additional or alternative therapy.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review, and interview, the HHA failed to ensure the physician signed the Missed Visit Forms for one of 10 patients ( Patient 8). This deficient practice had the potential for the physician not being updated regarding the actual visits and care being provided to the patient as ordered. A review of Patient 8’s clinical record on 5/7/22, at 8 a.m., indicated a start of care (SOC) 3/11/2022, with diagnoses of Krabbe Disease (an inherited disorder that destroys the protective coating (myelin) of nerve cells in the brain and throughout the nervous system with symptoms of unable to hold head, muscle weakness, and hearing/vision lost. There is no cure) and muscle weakness. During a review of the plan of care (POC- CMS 485), for the certification period of 3/11/2022 to 5/9/2022, included Physical Therapy (PT) to visit one time a week for one week and two times a week for one week and one time a week for seven weeks to include mobility training, transfer training, therapeutic exercise program, safety training, fall prevention, and caregiver training to improve independence with functional mobility to decrease fall risk. Occupational therapy was included to evaluate and treat. Review of Patient 8's Missed Visit Form dated 3/16/2022, 3/19/2022 , and 3/28/22, were not signed by the physician to indicate the physician was informed of the missed visits. During a joint record review and interview with the Director of Nurses on 5/8/2022, at 12: 03 pm., stated the missed visit forms should have been signed by the physician.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to coordinate care and services to meet one of 10 sample patients (Patient 6) social needs. This deficient had caused in Patient 6's transportation needs not being followed up. A review of Patient 6’s clinical record on 5/6/22, at 5 p.m., indicated a start of care (SOC) date of 3/13/2022, with diagnoses of Krabbe Disease (an inherited disorder that destroys the protective coating (myelin) of nerve cells in the brain and throughout the nervous system with symptoms of unable to hold head, muscle weakness, and hearing/vision lost. There is no cure) and muscle weakness. During a review of the plan of care (POC- CMS 485), for the certification period of 3/18/2022 to 5/16/2022, included Physical Therapy (PT) to visit one time a week for one week and two times a week for four weeks to include mobility training, transfer training, therapeutic exercise program, safety training, fall prevention, and caregiver training to improve independence with functional mobility to decrease fall risk. Occupational therapy was included to evaluate and treat. During a joint home visit with LVN 1, on 5/7/2022, at 11: 00 a.m., the patient caregiver complained about PT not showing up regularly and the Social worker not following up with the transportation. Patient 6 stated she had not seen PT in over a week and had some questions for the social worker. During a joint record review and interview with the Director of Nurses on 5/8/2022, at 12: 03 pm., review of Patient 6’s Physician Order dated 3/18/22, documented, “Hold PT until OT visits are completed.” Review of the HHA’s Medical Social Services Evaluation and Plan of Care Form dated 10/20/22, indicated Patient 6 needed transportation assistance and the Social worker was to evaluate & 1 follow up visit within 60 days. There was no documentation in Patient 6’s clinical record that both patient and caregiver were informed of the physician's order to Hold in PT and the Social worker followed up. During an interview with the Administrator and the DON on 5/8/22, at 12:30 p.m., they both stated coordination should have been provided to Patient 6. Review of the HHA’s policy and procedure on Medical Social Worker Services not dated stipulates, “ Medical Social Worker service shall include , but not be limited to: Documenting the initial assessment, re-assessment, interventions, and periodic evaluations in clinical record notes in a timely manner.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to screen the visitors for signs and symptoms of COVID 19 infection (an acute serious respiratory illness), and failed to develop the policy and procedures for COVID 19 prevention of the infection. This failure has the potential to spread the infection. During an observation on 5/6/22, at 3:30 p.m., upon entrance to the HHA, there was no screening for COVID-19 signs and symptoms, and no temperature checks were performed to the visitors entering the facility. An interview was conducted with the Director of Patient Care Services (DPCS) on 5/6/22, at 4 p.m., she stated that agency screen employees and document screening on the computer, but she did not know she had to also screen visitors. During a review of the infection control policy on 5/8/22, at 10:30 a.m., the HHA did not have a policy for COVID-19 that included surveillance, identification, control, prevention, and investigation of this contagious disease. The DPCS stated she would have to create a COVID-19 policy. DPCS also stated she would have to follow up with the fit testing for all staff. DPCS stated that most of the staff have been fit tested but she could not provide the evidence that the staff were fit tested. The undated HHA's policy and procedure titled, "Infection Control Plan" indicated the organization will address surveillance, prevention, identification, control and reporting of infections, utilizing current scientific methods and epidemiologic principles.